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Australian Dental Journal 2009; 54:(1 Suppl): S70–S85

doi: 10.1111/j.1834-7819.2009.01145.x

Strategies for the endodontic management of concurrentendodontic and periodontal diseases

PV Abbott,* J Castro Salgado*

*School of Dentistry, The University of Western Australia.

ABSTRACT

Endodontic and periodontal diseases can provide many diagnostic and management challenges to clinicians, particularlywhen they occur concurrently. As with all diseases, a thorough history combined with comprehensive clinical andradiographic examinations are all required so an accurate diagnosis can be made. This is essential since the diagnosis willdetermine the type and sequence of treatment required. This paper reviews the relevant literature and proposes a newclassification for concurrent endodontic and periodontal diseases. This classification is a simple one that will help cliniciansto formulate management plans for when these diseases occur concurrently. The key aspects are to determine whether bothtypes of diseases are present, rather than just having manifestations of one disease in the alternate tissue. Once it isestablished that both diseases are present and that they are as a result of infections of each tissue, then the clinician mustdetermine whether the two diseases communicate via the periodontal pocket so that appropriate management can beprovided using the guidelines outlined. In general, if the root canal system is infected, endodontic treatment should becommenced prior to any periodontal therapy in order to remove the intracanal infection before any cementum is removed.This avoids several complications and provides a more favourable environment for periodontal repair. The endodontictreatment can be completed before periodontal treatment is provided when there is no communication between the diseaseprocesses. However, when there is communication between the two disease processes, then the root canals should bemedicated until the periodontal treatment has been completed and the overall prognosis of the tooth has been reassessed asbeing favourable. The use of non-toxic intracanal therapeutic medicaments is essential to destroy bacteria and to helpencourage tissue repair.

Keywords: Endo-perio diseases, endodontics, periodontics.

INTRODUCTION

Although there are many factors that contribute tothe development and progression of endodontic andperiodontal diseases, the primary cause of bothdiseases is the presence of bacterial infections withcomplex microbial flora. Many authors have reportedthe similarity of the bacterial flora associated withendodontic and periodontal infections1–5 and it iswidely accepted that an untreated infection of one ofthese tissues can lead to signs or symptoms of diseasewithin the other tissue.6–10 Cross-seeding of bacteriafrom one tissue to the other can also occur10 and thiscan occur in either direction (i.e., from the root canalto the periodontium, or vice versa) through commu-nication pathways (Fig 1) such as the apical foramen,lateral canals, accessory canals (i.e., small canals thatrun from the floor of the pulp chamber to thefurcation region of multi-rooted teeth), dentinaltubules, developmental defects (e.g., radicular grooves,invaginations) and other disease-related or iatrogenic

defects of the tooth root (e.g., caries, cracks, perfora-tions).

Once both the pulp and the periodontal tissues havebecome involved, the diagnosis and management of thesituation may become more complex and will requireextra considerations. The prognosis will be less pre-dictable and patients may be unwilling to committhemselves to the treatment, as well as the financial andtime burdens required to salvage the tooth, and toretain and maintain it in the long term.11

Traditional approaches to assessing and managingteeth with concurrent endodontic and periodontaldiseases have been somewhat confusing as a result ofinconsistent, inaccurate and confusing terminology.Although there has been considerable research aboutthis topic in the past, there has been little researchreported in the last decade. The aims of this paper wereto review the literature, to develop a simple classifica-tion system and to provide a rational approach tomanaging teeth with concurrent endodontic and peri-odontal diseases.

S70 ª 2009 Australian Dental Association

Previous discussions of this topic have typicallyincluded all interactions between the dental pulp andthe periodontal tissues rather than being limited to teethwith concurrent endodontic and periodontal diseases.In this paper, only the latter will be discussed in detailbut a brief outline of the former will be provided toassist with the understanding of the proposed classifi-cation system.

Pulp and periapical conditions that may haveperiodontal manifestations

Some endodontic diseases may have manifestations thataffect the periodontal tissues. In particular, a chronicapical abscess may appear to be associated with aperiodontal pocket. A chronic apical abscess is definedas a localized collection of pus with a draining sinus –the abscess is located in the periapical region of a tooth

and is typically a result of an infected root canal system.The draining sinus may exit the mucosa in any location,either close to or at some distance from the abscess. Insome cases, the draining sinus may be located imme-diately adjacent to, or alongside, the gingival sulcus(Fig 2) and this can have the appearance of a deep,narrow periodontal pocket.12 In other cases, thedraining sinus may be tracking through the periodontalligament itself, although this would seem unlikely tooccur in a tooth with a healthy periodontal ligament.12

The furcation region of multi-rooted teeth may have aradiolucency (Fig 3) if there are accessory canalsdraining into the furcation. The root canal infectionmay be in one or more canals and may occur in teeththat have pulpless and infected root canal systems or inteeth that have been previously endodontically treated(Fig 3). Irreversible pulpitis rarely, if ever, will causeperiodontal or osseous defects, although it is possiblethat one canal may have irreversible pulpitis while oneor more of the other canals or the pulp chamber isinfected – this situation has been termed ‘‘pulp necro-biosis’’.13,14 The history together with the clinical andradiographic examination will generally reveal a factorthat has caused the pulp necrosis and subsequentinfection (e.g., caries, a crack, marginal breakdown ofa restoration, trauma, etc.).

Chronic apical abscesses have little or no discomfortunless an acute exacerbation occurs such as when thedraining sinus closes but pus is still being produced and

(a)

(b)

(c)

Fig 1. Schematic representation of some of the possible communica-tion pathways between the dental pulp and the periodontal ligament.(a) Longitudinal section of a tooth and its periapical and periodontal

tissues. A – the apical foramen; B – a lateral canal; C – dentinaltubules; D – an accessory canal. (b) – Cross-section of a tooth root.E – a radicular groove or invagination. (c) Cross-section of a tooth

root. F – a crack in the tooth root.

Fig 2. Schematic representation of a chronic apical abscess witha draining sinus tracking alongside the periodontal ligament andexiting the tissues inside the gingival sulcus, giving the clinical

appearance of a deep narrow periodontal pocket. The root canalsystem is pulpless and infected.

ª 2009 Australian Dental Association S71

Management of endodontic and periodontal diseases

is trapped deep within the tissues. The diagnosis ofthese cases should be based on the status of both theroot canal system and the periodontal tissues (e.g., apulpless, infected root canal system with a chronicapical abscess as a result of caries). Comprehensiveclinical classifications have been suggested for the statusof the periapical tissues15 and for the pulp and rootcanal system.14 In addition to noting the diseases thathave been diagnosed in such cases, the clinical recordshould also include a notation regarding the presenceand location of the draining sinus ⁄ periodontal defect soits presence and healing can be reassessed following theinitiation of treatment.

Periodontal conditions that may affect the pulp and ⁄ orperiapical tissues

Periodontal diseases may lead to changes in the state ofthe pulp tissue in several ways. Pulp inflammation(pulpitis) and secondary dentine formation has beenreported as being associated with periodontal dis-eases,6,7 as has internal resorption.6 These pulpchanges were reported to only occur when theperiodontal pockets extended deep enough to involvelateral canals or dentinal tubules associated withexposed root dentine or root caries.6,7 Complete pulpnecrosis did not occur unless the periodontal pocketextended all the way to the main apical foramen andthe foramen had been invaded by plaque.6,7 Oncecomplete pulp necrosis occurs, infection of the rootcanal system is to be expected with the subsequentdevelopment of apical periodontitis since bacteria fromthe periodontal pocket may invade the necrotic pulptissue once the pulp has lost its ability to resist suchbacterial invasion.

Periodontal treatment may also cause pulp inflam-mation, although usually only in the form of reversiblepulpitis which subsequently resolves after one to twoweeks but may occasionally persist and become irre-versible pulpitis. Root planing is an operative procedureof the tooth that may cause pulp inflammation ofvarying degrees, depending on the extent of theprocedure itself, the amount of cementum removed,whether the exposed dentine is protected by a smearlayer and the ability of the pulp to respond to anyirritant. The latter is usually entirely dependent on theoverall health of the pulp and this also depends to someextent on the history of any previous insults to the pulpand whether these caused pulp fibrosis in the portion ofthe pulp that is being irritated by the periodontaltreatment. Typically, patients with reversible pulpitisreport sensitivity of the root-planed tooth to coldstimuli, and occasionally sensitivity to hot stimuli. Thepain induced by the stimulus usually only lasts for a fewseconds after the stimulus has been removed, and thenresolves within one to two weeks.

(b)

(a)

(c)

Fig 3. An example of how a toothwith a chronic periapical abscessmayappear to also have a periodontal pocket. The management of this

situation is also illustrated by this case. (Reproduced with permissionand courtesy of the Journal of the New Zealand Society of Periodon-tology). (a) Pre-operative radiograph of a root-filled lower left first

molar tooth that had an infected root canal system and a chronic apicalabscess. The draining sinus was located on the mid-buccal aspect of thetooth with its external opening being inside the gingival sulcus, thusappearing to be a deep narrow periodontal pocket. The root canalfilling was technically inadequate with only two of the four canals

having been treated previously. The periapical radiolucency extendedto the furcation region of this tooth. (b) Periapical radiograph takenimmediately after placing the root canal filling which was done three

months after removal of the previous root canal fillings, thoroughcleaning, irrigation and medication of all four canals with a 50:50 mixof Ledermix and calcium hydroxide pastes. Early radiographic signs of

periapical and furcation bone repair are evident and there were nofurther clinical signs of a draining sinus after the initial cleaning of theroot canal system. (c) Six-month review radiograph shows complete

bone repair. Clinically, there were no signs of a draining sinus and noperiodontal treatment was required at any stage.


PV Abbott and JC Salgado

In some patients, the bone loss associated with a verydeep periodontal pocket may extend beyond the rootapex. In this situation, it can mimic a periapicalradiolucency15 which may suggest that the tooth hasan infected root canal system with chronic apicalperiodontitis (Fig 4). A careful and thorough examina-tion of the tooth, which must include pulp sensibilitytesting, is essential in these cases to ensure that anincorrect diagnosis is not made since this will lead tounnecessary and incorrect treatment of the problem.Teeth with infected root canal systems should beexpected to have a reason for the pulp necrosis to haveoccurred (e.g., caries, cracks, breakdown of restora-tions, fractures, trauma, etc.) and there should be apathway of entry for the bacteria to have reached theroot canal system in order to establish the infection. Ifneither the reason for necrosis nor the pathway of entryfor the bacteria can be established, then the diagnosingclinician should be suspicious of a periodontal pocketthat is mimicking a periapical radiolucency, andappropriate referral or management should be insti-gated. The pocket and the pulp can then be reassessedfurther after a period of time for initial healing.

Classification of endodontic-periodontal diseases

Several classifications of the so-called ‘‘endo-periolesion’’ have been suggested in the dental literaturebut most of these are not entirely satisfactory. Acommonly-used classification for endodontic-periodon-tal diseases was first suggested by Simon et al.16 andlater modified by Gargiulo.17 This classification in-cluded five categories which were based on the conceptof having primary and secondary diseases: (1) primaryendodontic lesion; (2) primary endodontic lesion with

secondary periodontal involvement; (3) primary peri-odontal lesion; (4) primary periodontal lesion withsecondary pulp involvement; and (5) ‘‘true combined’’endodontic-periodontal lesion.

However, this classification is not universallyaccepted as it is confusing. The confusion arises fromthe terminology used since the two primary conditionsare essentially ‘‘single site’’ diseases (i.e., solely end-odontic or periodontal diseases) and, as such, they arenot combined endodontic and periodontal diseases.11 Inaddition, when there are ‘‘secondary’’ diseases present,it is not usually possible to distinguish these from ‘‘truecombined’’ lesions since it is not possible to determinewhich tissue was the first one to be affected, orinfected.11

Weine18 proposed a classification based on treatmentneeds rather than on the diagnosis of the problem. Sucha classification is unacceptable since the disease shouldbe diagnosed before considering the treatment required,rather than the other way around. In addition, treatmentneeds can vary considerably for different cases with thesame disease process and therefore this classificationcan be misleading. Another classification, proposed byGuldener,19 was based on both the cause of thedisease(s) and the treatment needs rather than just onthe cause. His classification also included other prob-lems and conditions (such as perforations, root resorp-tion, root fractures, invaginations, grooves, etc.). Whilstit is recognized that these other problems can involveboth the pulp and the periodontal tissues, they are notstrictly combined or concurrent endodontic and peri-odontal diseases since they have particular reasonsand ⁄ or causes for the condition. As an example, avertical root fracture usually has an infected root canalsystem and a periodontal infection but these infectionsare a direct result of the fracture – hence the toothshould be diagnosed as having ‘‘a vertical root fracturethat is infected and causing apical periodontitis and aperiodontal abscess’’ (although such a fracture couldalso manifest as other periapical and ⁄ or periodontalconditions). Whilst it could be argued that all inter-relationships between endodontic and periodontalconditions should be included in a classification ofendodontic and periodontal diseases, having such abroad classification is unnecessary since these conditionsare specific problems with their own diagnostic criteriaand recommended management protocols. In addition,they are not all diseases or lesions – such as develop-mental conditions. Guldener’s classification also has thesame disadvantage of Weine’s classification in that ituses treatment needs to classify the diseases rather thanthe signs, symptoms and causes of the disease.

Another commonly-used classification was first sug-gested in a textbook chapter by Torabinejad andTrope20 and was based on the origin of the periodontalpocket, as follows:

Fig 4. Schematic representation of a periodontal pocket mimickinga periapical radiolucency. Note that the apical blood vessels and pulp’snerve supply are intact. If the tooth is not carefully examined andtested with pulp sensibility tests, this radiographic ‘‘lesion’’ could bemistaken as being a sign of chronic apical periodontitis because ofpulp necrosis and infection of the root canal system. (Reproducedwith permission and courtesy of Wiley-Blackwell, publishers of

Endodontic Topics.)



(1) Periodontal pocket of endodontic origin;(2) Periodontal pocket of periodontal origin;(3) Combined endodontic-periodontal lesion;

• separate endodontic and periodontal lesionswithout communication

• endodontic and periodontal lesions with com-munication.

However, the first two categories of this classificationare essentially ‘‘single site’’ diseases which are notcombined endodontic and periodontal diseases11 eventhough each one may have some affect on the othertissue, as discussed above. Interestingly, a later editionof the same textbook did not use this classificationagain and instead reverted to the classification sug-gested by Simon et al.16 although there were differentauthors for this chapter in the later edition.21

A clinically useful classification should be clear andeasy to understand. It should also be based oninformation that can be obtained from the historyprovided by the patient along with the findings of theclinical examination and other diagnostic proceduressuch as percussion, palpation, mobility testing, pulpsensibility tests, periodontal probing and periapicalradiographs which are all particularly useful, andessential, for diagnosing endodontic and periodontalconditions. It is therefore proposed that the classifica-tion of endodontic and periodontal diseases be limitedto those teeth that have both endodontic and periodon-tal diseases occurring at the same time – hence, it isproposed that they should be called ‘‘concurrentdiseases’’ rather than ‘‘combined endo-perio lesions’’since the suggested term is more appropriate as well asbeing more accurate, clinically useful and easy to use.Hence, only two categories are required, as follows:

(1) Concurrent endodontic and periodontal diseaseswithout communication

This applies to a tooth that has an infected root canalsystem with some form of apical periodontitis PLUSmarginal periodontal disease with pocketing but theperiapical and periodontal diseases do not communi-cate with each other (Fig 5). That is, clinically whenprobing the periodontal pocket it does not extend as faras the periapical lesion; radiographically the periodon-tal pocket does not extend as far as the apical foramenof the root canal, and bone can be seen between, andseparating, the periapical radiolucency and the base ofthe periodontal pocket.

(2) Concurrent endodontic and periodontal diseaseswith communication

This applies to a tooth that has an infected root canalsystem with some form of apical periodontitis PLUSmarginal periodontal disease with pocketing that

extends to the periapical lesion such that the periapicaland periodontal diseases communicate with each other;radiographically the periodontal pocket and the peri-apical radiolucency appear as one radiolucency, andthere is no bone between the periapical radiolucencyand the base of the periodontal pocket (Fig 6).

Teeth that have concurrent endodontic and peri-odontal diseases have two simultaneously-occurringdisease processes and fortunately they are relativelyuncommon although incidence data has not beenpublished in the literature. One disease process is theperiapical inflammatory response that has developed asa result of infection of the root canal system, whilst theother disease process is an independent periodontalpocket that is progressing towards the root apex – thisperiodontal pocket is a result of bacteria-inducedperiodontal disease. Initially the diseases do not com-municate (Fig 5) but if they are left to progress over aperiod of time, then they may eventually meet (Fig 6).

Teeth with concurrent endodontic and periodontaldiseases will have clinical and ⁄ or radiographic signs ofboth endodontic and periodontal involvement. Thediagnosis of both conditions can usually be made after athorough clinical and radiographic examination. End-odontic diseases are largely diagnosed via a combina-tion of the results of pulp sensibility tests and theradiographic observations with the latter providingvery definitive evidence of the presence of an infectedroot canal system.22 This was clearly shown in amonkey study where the radiographic periapical

Fig 5. A lower left first molar tooth with concurrent endodontic andperiodontal diseases that do not communicate. This tooth has a

pulpless, infected root canal system with chronic apical periodontitisas a result of breakdown of the amalgam restoration and the presenceof mesial caries. There was no response to pulp sensibility testing

and the radiograph shows a small periapical radiolucency associatedwith the mesial root. The patient has generalized marginal periodontaldisease with the typical deep, wide-based periodontal pocket seen withperiodontal disease. The radiograph shows more advanced crestalbone loss associated with this tooth than with the adjacent teethwhich have clinically normal pulps. (Reproduced with permission

and courtesy of the Journal of the New Zealand Society ofPeriodontology.)



changes – such as a widened periodontal ligamentspace, loss of lamina dura, and a periapical radio-lucency – only occurred once the root canal system hadbeen infected for some time.22 The periapical radio-graphic signs were not visible until 2–4 months, andeven up to more than 10 months in some cases, afterthe canals had been intentionally infected with bacteria.Inflammatory changes in the periapical region werenoted histologically well before the radiographic signscould be seen. Therefore, once a periapical radio-lucency is present, a diagnosis of an infected root canalsystem will be accurate and reliable although practitio-ners should always be aware of the possibility thatthe radiolucency may indicate other pathosis that isunrelated to the condition of the pulp or root canalsystem.15

The diagnosis of periodontal diseases is usually basedon a combination of the findings of periodontal probingand radiographic examination. Periodontal diseaseleads to periodontal pockets with distinct probingpatterns – the defects are usually wide-based andcone-shaped with the probe ‘‘stepping down’’ progres-sively to deeper levels, followed by ‘‘stepping up’’ onthe other side of the pocket.17,23 This probing patternmarkedly differs from that of the deep, narrow defect

associated with chronic apical abscesses (as discussedabove), vertical root cracks and fractures that havebecome infected. Radiographs usually show generalizedvertical and horizontal bone loss along the root surfacesat various levels, and there are usually multiple teethwith periodontal disease rather than just a single toothwhereas, in contrast, it is uncommon (although possi-ble) for patients to have multiple teeth with infectedroot canal systems at the same time.

Concurrent endodontic and periodontal diseasesusually do not present with any symptoms unless anacute exacerbation of one of the infections has occurred –such as an acute apical abscess or an acute periodontalabscess. In such a situation, the usual diagnostic criteriacan be applied to differentiate between these two typesof abscesses so appropriate treatment can be instigatedas soon as possible.

Differential diagnosis

The most important part of managing any disease is toestablish the correct diagnosis. This is just as importantwhen dealing with concurrent endodontic and peri-odontal diseases as an accurate diagnosis will then leadthe clinician to an appropriate management plan. Thediagnosis must be based on a combination of thehistory obtained from the patient, the clinical exami-nation findings, the radiographic observations, and theresults of all tests and investigations. In particular, pulpsensibility tests (ideally both thermal and electric),periodontal probing, palpation, percussion, mobilitytesting, transillumination of the tooth, and removingexisting restorations are valuable and essentialdiagnostic steps to help differentiate between pulp ⁄periapical diseases and periodontal diseases.11 Table 1summarizes the common clinical and radiographicfindings when examining a patient for endodontic andperiodontal diseases.

The clinical diagnosis of the pulp status can bedifficult at times. Unfortunately, there is no single testavailable that will accurately and reliably determine thetrue status of the pulp or root canal in all cases. Thecommonly-used thermal and electric pulp sensibilitytests can only indicate the ability of the pulp’s nervesupply to respond to that particular stimulus. Thesetests do not provide any information about the presenceor absence of the pulp’s blood supply, which is morerelevant when determining whether the pulp is healthyor diseased.14 However, reliable pulp and root canaldiagnoses can be made with a thorough understandingof the disease processes, the nature of the test and themeaning of the test results.

Pulp sensibility tests cannot be interpreted accuratelywithout the use of periapical radiographs since condi-tions such as pulp canal calcification, previous rootfillings, pulpotomies, porcelain crowns, etc., can lead to

Fig 6. A lower right first molar tooth with concurrent endodontic andperiodontal lesions that communicate. This tooth has a pulpless,

infected root canal system with a chronic apical abscess as a result ofbreakdown of the amalgam restoration and the presence of distalcaries. There was no response to pulp sensibility testing and the

radiograph shows a gutta percha ‘‘tracer point’’ placed in the distalperiodontal pocket which demonstrates that the pocket extends to,and communicates with, the periapical radiolucency associated withthe distal root. The patient has generalized marginal periodontal

disease with the typical deep, wide-based periodontal pocket seen withperiodontal disease. The radiograph shows significant crestal bone

loss associated with this tooth whereas the adjacent teeth have not hadmuch bone loss. The adjacent teeth also have clinically normal pulps.The food pack between the first and second molar teeth is a likely

contributory factor to both the endodontic and periodontal problemsbeing experienced with the first molar tooth. (Reproduced with

permission and courtesy of the Journal of the New Zealand Societyof Periodontology.)



false test results. Hence, good quality diagnosticradiographs are essential for the diagnosis of allendodontic and periodontal diseases. Radiographsshould be used to determine whether the periapicaland periodontal regions are involved, to determine thesize, shape and extent of any bone loss, and to assesswhether other diseases or causative factors are present –such as caries, an overhang, a deep restoration, etc.Radiographs and pulp sensibility tests are also essentialto help differentiate between odontogenic and non-odontogenic lesions. All radiographs should be takenwith film holders that incorporate beam guidance sothat a parallel view is obtained since this provides themost accurate representation of the tooth and itssupporting structures. Beam guidance devices also helpto ensure that a reproducible view is obtained sosubsequent films of the same tooth can be compared tothe initial film. This is extremely important whenassessing the healing response after treatment or iffurther problems develop in the future.

Teeth with previous endodontic treatment must beassessed with extreme caution since radiographs do notprovide information regarding the quality of theendodontic treatment or the root canal fillings.24

Radiographs essentially only show how radiopaquethe root filling material is and where the material has

been placed.25 It is important to recognize that a toothwith a radiographically-determined good root canalfilling can still contain bacteria24 and this must beconsidered carefully when formulating a managementplan for diseased teeth.

Radiographs can also be misleading if not interpretedcautiously – such as when a periodontal pocket mimicsa periapical radiolucency,15 as outlined earlier andshown in Fig 4.

Important considerations for managing concurrentendodontic and periodontal diseases

There are many factors that may affect the progressionof both endodontic and periodontal diseases. Thesefactors may also affect the outcome of any treatmentprovided. When treating teeth with concurrent end-odontic and periodontal diseases, there are also theadditional effects of the treatment of one tissue on thepartner tissue that need to be considered.11 Researchhas clarified some of the interactions between these twodisease processes and the results of these studies can beused to formulate a logical sequence for treatingconcurrent diseases. In particular, care must be takento minimize the risks of cross-seeding of bacteria10

whilst also providing optimum conditions in which

Table 1. Typical findings of clinical and radiographic examinations when assessing pulp and periapical diseases,periodontal diseases and concurrent endodontic and periodontal diseases. These findings can be used todifferentiate between these different diseases. CODE: Yes = this finding is usually present; No = this finding is notusually present. However, there are many variations which must be assessed for each individual case withappropriate diagnostic tests and a thorough clinical and radiographic examination

Typical findings Pulp and periapical diseases Periodontal diseases Concurrent endodontic andperiodontal diseases

Disease process localizedto just one tooth

Yes No Yes – but may have more than onetooth involved if the patient hasgeneralized marginal periodontaldisease

Extensive caries or restorations Yes No Yes – likely there is pulp ⁄ periapicaldisease present

Responds to pulp sensibilitytests

No Yes No – due to the pulp ⁄ periapicaldisease process

Periodontal probing defect No – but may have a deep,narrow probing defect ifthere is a draining sinusthat exits in the gingivalsulcus

Yes – usually a deep,wide-based pocket

Yes – usually a deep, wide-basedpocket due to the periodontaldisease process

Crestal bone loss evident onradiographs

No Yes Yes – usually a deep, wide-basedpocket due to the periodontaldisease process

Periapically – loss of laminadura or the presence of aradiolucency

Yes No Yes – due to the pulp ⁄ periapicaldisease process

Tenderness to percussionand ⁄ or palpation

No – unless acute apicalperiodontitis or acuteapical abscess is present;may ‘‘feel different’’if chronic apicalperiodontitis is present

No – unless acuteperiodontal abscess ispresent; may ‘‘feeldifferent’’ if chronicmarginal periodontitisis present

No – unless acute apicalperiodontitis, acute apical abscessor acute periodontal abscess ispresent; may ‘‘feel different’’ ifchronic apical periodontitis orchronic marginal periodontitis ispresent



periapical and periodontal healing can occur. Themajor findings of a number of important studies aresummarized below.

(1) Infected root canal systems and periodontal pock-ets have similar microbiological flora2,4,5,8–10 althoughthere are more spirochaetes in periodontal pockets thanin infected root canal systems. Several studies1,3,5 haveshown that 30–60 per cent of the microbial flora inperiodontal pockets are spirochaetes whereas 0–10 percent of the organisms from infected root canal systemsare spirochaetes. In general, there are more microbes andmore species in periodontal pockets than in infected rootcanal systems, and the microflora in infected root canalsof teeth that have concurrent endodontic and periodon-tal diseases is more complex than in teeth with pathosisconfined to the periapical region.5

(2) The periodontal pocket may be a source ofbacteria for the root canal system8–10 or vice versa, andcross-seeding of bacteria can occur in either direction.10

(3) The long-term prognosis for periodontally-involved teeth is more favourable for teeth withclinically normal (i.e., healthy) pulps than for end-odontically-treated teeth as demonstrated by Jaouiet al.26 In that study, 6 per cent of the 195endodontically-treated teeth were extracted over eightyears after periodontal treatment whereas none of the521 teeth with clinically normal pulps were extractedduring this time.

(4) Lindskog et al.27 demonstrated that periodontalhealing adjacent to cementum favours connective tissueformation whereas healing adjacent to dentine favoursrapid downgrowth of gingival (i.e., long junctional)epithelium. This strongly suggests that treatmentshould be sequenced to take advantage of the morefavourable healing response associated with the pres-ence of cementum, especially when the root canal isalso infected (see below).

(5) A series of studies22,28–32 concerning the influ-ence of infected root canal systems on marginalperiodontitis in monkeys and periodontitis-pronehuman patients clearly demonstrated that:

• an intracanal infection can invoke an inflamma-tory response along the lateral surfaces of a toothroot;

• intracanal infections were correlated with deeperperiodontal pockets, more loss of attachment,and more marginal epithelium in periodontitis-prone patients;

• the average radiographic attachment loss in teethwith an infected root canal system in periodon-titis-prone patients over a six-year period wassignificantly higher than the radiographic attach-ment loss caused by marginal periodontitis inteeth with normal pulps;

• the influence of an intracanal infection was atleast of the same order of magnitude as a risk

factor for periodontal disease as an overhangingrestoration.

(6) Local factors that modify marginal periodontalhealing have been investigated in monkeys andwith clinical studies in periodontitis-prone humanpatients.33–35 These studies showed that:

• infected root canal systems had significantlylarger areas of external inflammatory andreplacement root resorption when dentine sur-faces had been exposed through removal ofcementum;

• periodontal healing was at risk of being impairedwhen the root canal system was infected;

• following non-surgical periodontal treatment,the mean reduction of periodontal pocket depthwas significantly less over time in the presence ofinfected root canal systems compared to teethwith clinically normal pulps.

(7) Jansson36 and Ehnevid37 have both stated thatendodontic infections must not be overlooked andshould be given priority in treatment planning forperiodontitis-prone patients.

When planning treatment of concurrent endodonticand periodontal diseases, the above findings stronglyindicate that the timing of the endodontic treatmentis an important consideration. As mentioned above,a root canal infection has significant effects on theoutcome of periodontal treatment. However, in addi-tion to this, the outcome of endodontic treatment maybe affected if the root canal filling is placed while thereis still a periodontal infection present that communi-cates with the root canal system since cross-seedingthrough the apical or lateral foramina is possible.Despite thorough cleaning and disinfection of the rootcanal system during endodontic treatment, bacteriafrom the periodontal lesion may re-invade the rootcanal system since root canal fillings do not seal canalscompletely.38,39 Root canal fillings may ‘‘fill’’ the canalspace but there is no technique or material availablethat has been shown to provide a total, predictable andlong-term ‘‘seal’’, as demonstrated by over 150 apicalpenetration studies of root canal fillings.39 However,fortunately, the environment within the root canalsystem can be maintained in a state that is unfavourablefor bacterial colonization by using an anti-bacterialmedicament within the canals40,41 during the periodon-tal treatment, particularly if the dressing is replaced atregular intervals.42,43

The use of an intracanal medicament is consideredby many authorities to be essential when treating aninfected root canal system. Although there has been atrend over the last 10–15 years by some practitionersto use ‘‘one-visit’’ endodontic procedures on a routinebasis, this approach is not supported by the scientificevidence in the dental literature. In particular, thereare no well-documented long-term scientific studies



that demonstrate the outcome of ‘‘one-visit’’ endodon-tics. Proponents of this approach use a few studies thathave reported no difference in postoperative pain orshort-term success rates of 6–12 months. Neither ofthese aspects prove that the treatment is adequate atremoving the intracanal infection and they contradictthe comprehensive work of Bystrom et al.44–46 Thesestudies clearly showed that the mechanical cleaning ofa root canal (i.e., filing) and disinfectant irrigatingsolutions will reduce the bacterial count but they willnot completely eliminate all organisms. The use ofanti-bacterial intracanal medicaments are also requiredto predictably achieve bacteria-free canals prior toplacing a root filling. Two comprehensive clinical andmicrobiological studies47,48 have confirmed this andshown that there is a significantly lower rate of healingfor ‘‘one-visit’’ endodontic treatment when bacteriawere isolated from the canals after instrumentation butprior to root filling. The teeth that had no bacteriaisolated prior to the root filling had a 26 per centhigher rate of healing in one study47 and 47 per centdifference in another.48 Other studies49–52 have alsoshown similar results and clearly demonstrate that it isnot possible to predictably remove or inhibit allbacteria in an infected root canal system just by themechanical cleaning with files and irrigation withdisinfectant solutions. Hence, intracanal medication ishighly recommended in order to improve the predict-ability of disinfection of the canals and in turn toimprove the predictability of the outcome of endodon-tic treatment.

If it is accepted that an intracanal medicament isneeded, then the type of medicament to use is impor-tant. The use of a biocompatible medicament isessential to promote periodontal healing53 and there-fore increase the overall prognosis for the tooth. Leder-mix paste (Lederle Laboratories, Seefeld, Germany),a corticosteroid-antibiotic combination, has beenshown to be effective as an antibacterial agent withinthe root canal system and its anti-inflammatory actioncan reduce symptoms by decreasing the periodontal andperiapical inflammation.42,43,54,55 The corticosteroidcomponent of this material is also a very effectiveinhibitor of clastic cells56 and will help to reduce theincidence of external inflammatory root resorption.57

Further inhibition of root and bone resorption, andstimulation of bone healing is provided by the tetracy-cline component58 since tetracyclines are potent inhib-itors of osteoclasts and they bind to bone and tooth.This binding to tooth structure helps to maintain thedrug in the local region for a sufficient period of time toallow periodontal healing to occur. Tetracyclines alsoinhibit polymorphonuclear lymphocyte collagenase, anenzyme which leads to tissue destruction – hence theuse of Ledermix paste can help to reduce tissuebreakdown.58

Calcium hydroxide is also a very effective antibacte-rial agent when used within the root canal system and ithas been shown to stimulate hard tissue repair. How-ever, the latter effect is a result of its high toxicity whichcauses surface necrosis to occur. This toxic effect ofcalcium hydroxide is undesirable in tissue that is alreadyinflamed as a result of the disease process and thereforethe application of calcium hydroxide in the early stagesof treatment may initiate or exacerbate external inflam-matory root resorption if cementum is missing or hasbeen removed through root planing. Long-term use ofcalcium hydroxide is also associated with significantlymore ankylosis and external replacement root resorp-tion of teeth that have had damage to the external rootsurface, such as after trauma or periodontal disease andits treatment.53,59-61 Hence, calcium hydroxide mustbe used with care when any cementum is missing. Inaddition, calcium hydroxide cannot be relied upon toeliminate all bacteria in all cases – as demonstrated byseveral studies.46,62 This is a problem associated with allmedicaments and provides support for the use of morethan one medicament in infected teeth, either asseparate dressings or in combination. It is believed thatcombining Ledermix paste with calcium hydroxide willreduce the toxicity of the calcium hydroxide whilst stillmaintaining the therapeutic properties of each activecomponent and increasing the antibacterial spectrumof activity compared to when using Ledermix pastealone.42,43,63,64

General management strategies for endodontic andperiodontal infections masquerading as other diseases

Periodontal diseases that appear to be causing pulpchanges should initially be managed conventionally bythorough subgingival root planing, by removal of anylocal causative factors and with oral hygiene instruc-tion. This should be followed by review and reassess-ment of the healing response. Some cases will requirefurther root planing and ⁄ or surgical management togain better access to the root surface for plaque andcalculus removal. If the pulp symptoms continue, thenendodontic examination, diagnosis and managementwill be indicated. Since periodontal diseases and theirtreatment can cause pulp changes, it is essential toregularly re-examine periodontally-involved teeth forany changes in the status of the pulp and periapicaltissues. This includes repeating pulp sensibility tests atreview examinations and comparing the results tothose obtained at the initial examination. Any teeththat are susceptible to pulp changes and those withaltered pulp sensibility test results should have furtherperiapical radiographs taken and compared to thediagnostic films taken prior to treatment. The status ofthe pulp is dynamic and it may change over time sincethe pulp is a tissue that is capable of responding to



stimuli and changing conditions. Repeated insults willlead to pulp fibrosis and a reduced capacity to respondnormally63 and therefore pulp necrosis may occur at anytime in compromised teeth with subsequent infectionof the root canal system and then apical periodontitis.

Conventional endodontic treatment of an infectedroot canal system with a chronic apical abscess drainingalongside or through the periodontal ligament (Fig 1)should lead to healing of the apical abscess. If thedraining sinus masquerading as a periodontal pocketdoes not heal, then periapical surgery is usuallyindicated so the apical abscess can be curetted. Ideally,such surgery should be done at the same time as theplacement of the root canal filling in order to avoid thepossibility of any extra-radicular bacteria re-infectingthe filled root canal which may occur if the canal isfilled some time prior to surgery. If the periodontaldefect still does not heal after periapical surgicalintervention, then periodontal diagnosis and manage-ment may be required. After the root canal filling hasbeen completed, the tooth should be restored with asuitable restoration and scheduled for review. Everytooth that has undergone endodontic treatment shouldbe reviewed clinically and radiographically after6–12 months in order to determine whether adequateperiapical healing has continued. If periapical healing isevident and the periodontal situation is stable, thenfurther clinical and radiographic reviews should beconducted every 3–4 years to monitor the tooth, itsperiodontium and its restoration. As both endodonticand periodontal infections can recur, it is essential toreview and maintain the area so that early signs ofbreakdown can be treated before irreversible damageoccurs or before the required treatment becomes furthercomplicated.

Specific points to be emphasized in treating any toothwith an infected root canal system include:• the treatment should be carried out under aseptic

conditions using rubber dam isolation for all phases ofthe treatment including the final coronal restoration;

• the treatment should address the factor(s) thathas ⁄ have caused the intracanal infection – the typicalfactors are caries, cracks, fractures and breakdown ofa restoration in the tooth so these should all beremoved prior to endodontic treatment;66

• an adequate interim restoration must be placed tostabilize the tooth, to ensure no bacterial penetrationcan occur between appointments and after the rootfilling has been completed, and to avoid any irritationof the periodontal tissues;67 and

• it is essential to ensure disinfection of the root canalsystem prior to placing a root canal filling throughthe use of adequate mechanical debridement of thecanals, irrigation with antiseptic cleansing and sol-vent solutions, and appropriate intracanal medica-tion between appointments.42,43

If there is any doubt about the long-term prognosisof a tooth with a draining sinus that is masqueradingas a periodontal pocket, then a series of long-termintracanal dressings can be utilized (as outlined below)whilst the healing response is monitored.11,43 Once thehealing response and prognosis have been assessed asbeing adequate, then the root canal filling can becompleted.

Management strategies for concurrent endodontic andperiodontal diseases

Treatment of teeth with concurrent endodontic andperiodontal diseases must address both of the concur-rent problems. However, some debate exists within thedental literature as to which problem should be treatedfirst.11 The answer to this question partly relies on thediagnosis for each particular case since any acuteproblems (such as pain or swelling) must be treatedfirst in order to comfort and stabilize the patient.11

Hence, if the patient presents with an acute apicalabscess, then endodontic treatment should be com-menced immediately. However, if the patient presentswith an acute periodontal abscess, then periodontaltreatment should be commenced immediately. Once theinitial treatment has been provided, the disease that wascausing the acute problem will essentially return to achronic state until further treatment results in completehealing – such further treatment should follow theguidelines listed below. However, most patients withconcurrent endodontic and periodontal diseases do nothave any symptoms since these conditions are typicallychronic in nature. In such cases, the following treatmentguidelines should be followed.

Concurrent endodontic and periodontal diseaseswithout communication

Ideally, conventional endodontic treatment should becarried out prior to any periodontal treatment of atooth that has both endodontic and periodontal dis-eases without any obvious communication between thedisease processes (Fig 7).11 The root canals should bethoroughly cleaned, irrigated and medicated beforeplacing a root canal filling, and with all endodontictreatment being provided under aseptic conditions. Thetooth should then be adequately restored to preventfurther bacterial penetration from the oral cavity intothe tooth and root canal system. The restoration shouldalso provide correct contours without overhangs andfood pack areas which can complicate the periodontaltreatment and healing response. The periodontal treat-ment should be deferred until the root canal system isfree of bacteria since the presence of bacteria in the rootcanal system will affect the outcome of the periodontaltreatment in several ways. Periodontal treatment will



remove some cementum from the root surface to exposedentinal tubules which will allow bacteria and ⁄ or theirendotoxins to diffuse through the dentine to theperiodontal tissues – this delays periodontal healingand may lead to external inflammatory root resorp-tion.33–35 Endodontic infections also stimulate thedowngrowth of epithelium along denuded dentinesurfaces with marginal communication,27 amplify mar-ginal bone loss and deepen periodontal pockets oninstrumented root surfaces although teeth with gingivalrecession are at less risk of these problems occur-ring.28,29,31,32 Hence, the ideal order of treatment isroot canal treatment first followed by periodontaltreatment soon after.

Concurrent endodontic and periodontal diseases withcommunication

Teeth that have concurrent endodontic and periodontaldiseases that obviously communicate with each otherwill require comprehensive treatment with both end-odontic and periodontal management.11 Ideally, theyshould be managed concurrently (Figs 8–9) although inplanned and sequenced stages to reduce possiblecomplications from one disease entity (i.e., infection)affecting the outcome of the treatment of the otherproblem. That is, ideally both infections should beremoved before the root canal filling and any finalrestorations are provided.11 The general sequence oftreatment is the same as that outlined above forconcurrent diseases without communication exceptthat completion of the root canal filling should bedelayed until the periodontal prognosis has beenreassessed and determined following initial, and oftenfurther, periodontal treatment.11 Hence, the recom-mended approach to managing such cases is to:

(1) Commence the endodontic treatment first usingthe following protocol:

• under rubber dam isolation, remove all existingrestorations, caries and any cracks in the toothto allow thorough assessment of the suitabilityof the tooth for further restoration. If the toothis suitable, then continue the endodontic treat-ment as outlined below. If the tooth is notsuitable, then it should be extracted at thisstage;

(a)

(b)

(c)

Fig 7. Management of a lower right first molar tooth with concurrentendodontic and periodontal diseases that did not communicate. Theroot canal system was infected with chronic apical periodontitis as aresult of breakdown of the crown restoration. The tooth also had adeep periodontal pocket with significant loss of crestal bone height onthe mesial and buccal aspects. (Reproduced with permission and

courtesy of the Journal of the New Zealand Society of Periodontol-ogy). (a) The pre-operative radiograph shows that the existing root

canal filling is technically unsatisfactory, based on radiographicappearance. The mesial food pack problem is a likely contributing

factor to the periodontal pocketing in this area. (b) Periapicalradiograph taken after placement of a new root canal filling after

endodontic re-treatment of the tooth. This treatment involvedremoval of the crown, the amalgam core restoration and the root

canal filling flowed by medicating the root canals and constructing aninterim restoration with a stainless steel orthodontic band and a glassionomer cement. The canals were further cleaned, prepared, irrigatedand medicated over a three-month period. After the root filling wascompleted, the patient was referred back to his general dentist whoprovided routine conservative periodontal treatment to the tooth byroot planing, curettage and oral hygiene instructions. The dentist alsoreplaced the interim restoration with a new core restoration which

remained in place while the periodontal treatment was done.(c) Periapical radiograph taken three years after the new root canalfilling was completed. Good periapical bone repair is evident alongwith excellent bone repair in the mesial periodontal defect. There

were no clinical signs of periodontal pocketing and the tooth has beenrestored with a new full coverage crown. This tooth now has a

good prognosis provided the patient maintains excellent oral hygienein this area.



• thoroughly prepare, clean and irrigate the rootcanal system to help reduce the number of viablebacteria within the root canal system;

• place Ledermix paste as an initial medicament tocontrol any symptoms, to reduce the intracanalinfection, to reduce the periapical inflammatoryresponse42,43 and to arrest any external inflam-matory root resorption56,57 which may be pres-ent in up to 80 per cent of teeth with apicalperiodontitis;68

• construct an interim restoration (e.g., by usingglass ionomer cement with or without a stainlesssteel band, as required);67 the interim restoration

must not complicate the periodontal status, itmust not restrict access for the periodontaltreatment, and it must not affect the patient’sability to clean the tooth;

• change the intracanal medicament after fourweeks to a 50:50 mixture of Ledermix pasteand a calcium hydroxide paste such as Pulpdentpaste (Pulpdent Corporation, Watertown, MA,USA).42,43

(2) Commence periodontal treatment once the sec-ond dressing has been placed. The concept is to pro-vide the initial periodontal treatment while the rootcanals are still medicated since this creates the mostunfavourable environment for bacterial survival.Typically, non-surgical root planing and oral hygieneinstructions are sufficient for the initial periodontalmanagement although some cases may need surgicalaccess for adequate root planing and cleaning at thisstage.

(3) Three months later, the periodontal healingresponse should be reassessed. If the response has beenfavourable, then the root canal filling can be placedfollowed by a suitable coronal restoration. The patientshould then be re-appointed for ongoing periodontalmaintenance and to review the periapical healingresponse on a regular basis. Such cases usually have areasonable prognosis (see below).

(4) Alternatively, if the initial periodontal responsehas not been favourable or is not ideal at the three-month review, then the root canal system should bere-medicated with a fresh mixture of Ledermix andPulpdent pastes and then further periodontal treat-ment – such as more root planing and ⁄ or periodontal

(c)

(b)

(a) Fig 8. Management of an upper left second premolar tooth withconcurrent endodontic and periodontal diseases that communicatedwith each other. The tooth had a pulpless, infected root canal systemwith chronic apical periodontitis as a result of breakdown of the

coronal restoration. It also had a deep periodontal pocket on the distalaspect. The patient also had generalized periodontal disease. (Repro-

duced with permission and courtesy of the Journal of the NewZealand Society of Periodontology.) (a) The pre-operative radiographshows a very deep metallic restoration and a periapical radiolucencycommunicating with the distal periodontal pocket. There has been

marked bone loss on the distal aspect. The radiograph also suggeststhat there is no contact point between this tooth and the first molartooth, and hence food packing may have been a contributory factor to

both the periodontal and endodontic problems. (b) Periapicalradiograph taken two months after treatment was commenced. Theroot canal system was cleaned and medicated, followed by initial rootplaning and oral hygiene instruction. At this stage, some periapical

bone repair is evident but there is still some distal periodontalpocketing so further periodontal treatment and re-dressing of the

canal were indicated. (c) Periapical radiograph taken at the time ofplacing the root canal filling which was done six months after the

initiation of endodontic treatment. Intracanal medications wereutilized while the periodontal treatment was provided. The peri-

odontal treatment initially involved root planing and oral hygieneinstruction. After three months, periodontal access surgery was

performed in order to facilitate further root planing. At this stage,periapical bone repair is evident as well as bone repair within the

distal periodontal pocket.



(a) (b)

(c)

(d)

(e)

Fig 9. Management of an upper left first molar with concurrent endodontic and periodontal diseases that communicated with each other. The toothhad a pulpless, infected root canal system with chronic apical periodontitis as a result of breakdown of the coronal restoration. It also had a deepperiodontal pocket on the mesial aspect. The patient was diabetic and had generalized periodontal disease. (Reproduced with permission and

courtesy of the Journal of the New Zealand Society of Periodontology.) (a) The pre-operative radiograph showed marked bone loss associated withthe mesio-buccal root and extending to the periapical region of this root. (b) Periapical radiograph taken immediately after placing the root canal

filling which was done seven months after the initiation of endodontic treatment. The canals were medicated throughout this time while theperiodontal treatment was provided. Initial root planing was followed by periodontal access surgery to allow better cleaning and to apically

reposition the gingival margin. There is evidence of mesial and periapical bone repair at this stage. (c) Clinical appearance at the time ofcompleting the root canal filling and after the periodontal surgery had been done. There has been some gingival recession as a result of theperiodontal disease and treatment, especially following apical repositioning of the flap during surgery. (d) A review radiograph taken six

months after completion of the root canal filling shows further bone repair on the mesial aspect. There was no periodontal pocketing presentand the tooth had no signs of active periodontal disease. (e) A review radiograph taken 10 years after endodontic and periodontal treatment

shows no progression of the periodontal disease and no further bone loss on the mesial aspect. Periodontal probing depths on the mesial aspectwere approximately 3 mm and there was only slight bleeding on probing.



flap surgery – should be arranged as soon as possible.Following such further periodontal treatment, the toothshould be reviewed again after another three months toreassess the healing response and to determine whetherthe prognosis has improved sufficiently to justify anyfurther treatment.

• If the healing has been adequate and theprognosis has improved at that stage, thenthe root canal filling can be completed and thecoronal restoration can be placed; this shouldthen be followed by ongoing reviews andperiodontal maintenance therapy as describedabove.

• On the other hand, if the response to the furtherperiodontal treatment has not been favourable,then the root canals should be re-medicated atthree-monthly intervals to allow further peri-odontal assessment and treatment to be pro-vided. Alternatively, if the periodontal prognosisis deemed to be poor at this stage, thenextraction should be considered. Some teethmay be suitable for procedures such as rootresection or hemisection, in which case the rootcanal filling should be completed immediatelyprior to these procedures being performed.

(5) In general and wherever possible, once the rootcanal filling has been completed, full coverage castcrowns should be deferred until after further reviewshave confirmed that the prognosis of the tooth and itsperiodontal condition justify such complex and costlyrestorative dental treatment. As an example, an amal-gam core restoration with cusp overlay can be usedduring this period of further reassessment.

Prognosis

The prognosis of teeth with concurrent endodontic andperiodontal diseases will initially be difficult to deter-mine in most cases prior to treatment, especially inthose teeth where the diseases communicate with eachother. Therefore, it is essential to continually reassessthe prognosis after each phase of treatment and afterappropriate time intervals to allow healing and stabil-ization of the tissues. The prognosis will depend onmany factors,11 some of which are:• the primary cause of the diseases• the amount of attachment loss prior to treatment• the patient’s healing responses• effectiveness of oral hygiene procedures used by the

patient• the patient compliance with seeking maintenance

therapy• the effectiveness of maintenance therapy, and• the longevity of any restorations.In general, the periodontal prognosis and the effective-ness of the patient’s oral hygiene procedures will be the

main determinants of the prognosis and the overalltreatment outcomes. The prognosis will usually bebetter if the endodontic and periodontal diseases do notcommunicate since they are effectively independentdiseases and the periodontal pocket is not as deep aswhen the diseases communicate.11

Concurrent diseases that communicate have theworst prognosis and are therefore more likely to requirefurther treatment. However, it is again emphasized thatthe prognosis cannot be easily determined until afterinitial endodontic and periodontal treatment have beenprovided. Any further proposed treatment must con-sider the effectiveness of the patient’s oral hygieneprocedures and the concurrent nature of the diseaseprocesses. The prognosis of further treatment will alsobe difficult to predict because of the multi-factorialnature of the diseases.

Since the long-term prognosis cannot always bereadily assessed prior to treatment, it is importantthat teeth are not quickly condemned for extractionand that all treatment options are considered.Generally, it is better to provide the appropriateinitial phases of treatment (e.g., root canal cleaningand medication plus root planing) before making anydefinite recommendations to the patient about otherprocedures, especially surgery or extraction. Manyteeth can be saved with good quality care and withregular professional maintenance but, as with allaspects of periodontal disease, the patient must carryout meticulous oral hygiene procedures in the areain order to keep the tooth free of plaque andcalculus.

CONCLUSIONS

Endodontic and periodontal diseases can providemany challenges to clinicians. Although there maybe difficulties in establishing a correct diagnosis, thisis the most important phase of their management asthe diagnosis will determine the type and sequence oftreatment required. In general, if the root canalsystem is infected, endodontic treatment should becommenced prior to any periodontal therapy in orderto remove the intracanal infection before any cemen-tum is removed. This avoids several complicationsand provides a favourable situation for tissue repair.The endodontic treatment can be completed beforeperiodontal treatment is provided except where thereis a ‘‘concurrent endodontic and periodontal lesionwith communication’’ – in these cases, the root canalsshould be medicated until the periodontal treatmenthas been completed and the overall prognosis hasbeen reassessed as being favourable. The use ofnon-toxic intracanal therapeutic medicaments isessential to destroy bacteria and to encourage tissuehealing.



ACKNOWLEDGEMENTS

The authors gratefully acknowledge the clinical skills,expertise and assistance of Drs Michael Lyons, LouiseBrown and Gareth Davies in providing the periodontaltreatment for the patients whose teeth are shown inFigs 7–9. The authors also gratefully acknowledge thegenerosity of the New Zealand Society of Periodontol-ogy, the Editor of the Journal of the New ZealandSociety of Periodontology, and the Wiley-BlackwellPublishing Co., publishers of Endodontic Topics, forallowing reproduction of some figures as noted in therelevant figure captions. This paper has been based on asimilar article that was published in the Journal of theNew Zealand Society of Periodontology in 1998.

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54. Abbott PV, Heithersay GS, Hume WR. The release and diffusionthrough human tooth roots in vitro of corticosteroid and tetra-cycline trace molecules from Ledermix paste. Endod Dent Trau-matol 1988;4:55–62.

55. Abbott PV, Hume WR, Heithersay GS. Barriers to diffusion ofLedermix paste in radicular dentine. Endod Dent Traumatol1989;5:98–104.

56. Pierce A, Heithersay G, Lindskog S. Evidence for direct inhibitionof dentinoclasts by a corticosteroid ⁄ antibiotic endodontic paste.Endod Dent Traumatol 1988;4:44–45.

57. Pierce A, Lindskog S. The effect of an antibiotic ⁄ corticosteroidpaste on inflammatory root resorption in vivo. Oral Surg OralMed Oral Pathol 1987;64:216–220.

58. Vernillo AT, Ramamurthy NS, Golub LN, Rifkin BR. The non-antimicrobial properties of tetracycline for the treatmentof periodontal disease. Curr Opin Periodontol 1994;2:111–118.

59. Lengheden A, Blomlof L, Lindskog S. Effect of immediate cal-cium hydroxide treatment and permanent root-filling on peri-odontal healing in contaminated replanted teeth. Scand J DentRes 1991;99:139–146.

60. Lengheden A, Blomlof L, Lindskog, S. Effect of delayed calciumhydroxide treatment on periodontal healing in contaminatedreplanted teeth. Scand J Dent Res 1991;99:147–153.

61. Blomlof L, Lengheden A, Lindskog S. Endodontic infection andcalcium hydroxide treatment. Effects on periodontal healing inmature and immature replanted monkey teeth. J Clin Perio1992;19:652–658.

62. Nair PRN, Sjogren U, Krey G, Kahnberg KE, Sundqvist G.Intraradicular bacteria and fungi in root-filled, asymptomatichuman teeth with therapy-resistant periapical lesions: A long-term light and electron microscopic follow-up study. J Endod1990;16:580–588.

63. Abbott PV, Hume WR, Heithersay GS. The effect of combiningLedermix and calcium hydroxide pastes on the diffusion of cor-ticosteroid and tetracycline through human tooth roots in vitro.Endod Dent Traumatol 1989;5:188–192.

64. Taylor MA, Hume WR, Heithersay GS. Some effects of Ledermixpaste and Pulpdent paste on pulp fibroblasts and on bacteriain vitro. Endod Dent Traumatol 1989;5:266–273.

65. Heithersay GS, Hume WR, Valdrighi L. Disease dynamics of thedentine, pulp, and periapical tissues. In: Prabhu SR, Wilson D,Daftary DK, Johnston NW, eds. Oral diseases in the tropics.Oxford: Oxford University Press, 1992.

66. Abbott PV. Assessing restored teeth with pulp and periapicaldiseases for the presence of cracks, caries and marginal break-down. Aust Dent J 2004;49:33–39.

67. Jensen A-L, Abbott PV, Castro Salgado J. Interim and temporaryrestoration of teeth during endodontic treatment. Aust Dent J2007;52(1 Suppl):S83–S99.

68. Laux M, Abbott PV, Pajarola G, Nair PNR. Apical inflammatoryroot resorption: a correlative radiographic and histologicalassessment. Int Endod J 2000;33:483–493.

Address for correspondence:Professor Paul Abbott

School of DentistryThe University of Western Australia

17 Monash AvenueNedlands WA 6009

Email: [email protected]



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